PulmCrit Wee- Communicating airway difficulty via the allergy list

Introduction with a case

I once admitted a patient in transfer for the management of heart failure. Prior to transfer, he was intubated at a community hospital. There was extreme difficulty intubating him, which apparently required an hour and led to substantial airway bleeding. Eventually he was intubated by an anesthesiologist using a bougie. The transferring physician wasn’t involved in the intubation, but attributed this difficulty to an airway polyp.

A few weeks later, while covering a night shift in the ICU, I was called to evaluate a patient in respiratory distress who required intubation. While preparing to intubate him, I asked the resident to check whether there were any records regarding prior intubation difficulty. There were none. We are about to initiate rapid-sequence intubation when the charge nurse walked by and asked “Hey Josh, isn’t this the guy with a terrible airway that took an hour to intubate?” Sure enough, it was him.

Given this history, we changed our strategy to an awake intubation. He did indeed have a mass affixed to his epiglottis which distorted his airway anatomy. However, he was awake and breathing, helping me to proceed without stress. With a Glidescope it was possible to position his head to allow visualization of the posterior cartilages (the view of the vocal cords was entirely obstructed). An endotracheal tube was gently slipped anterior to the posterior cartilages, and he was intubated safely within a few minutes (1).

Traditional documentation fails us in emergencies

There is agreement about the following:

If difficult airway anatomy is encountered, this should be documented in the patient’s records.

Prior to intubation, the patient’s records should be reviewed to see if the patient was previously difficult to intubate.

This is obvious. Unfortunately, in practice this information is scattered around a patient’s chart. For example:

Difficult intubation in the OR: This information is typically buried within a several-page anesthesiology report. In many hospital charting systems, the anesthesiology records are difficult or impossible to retrieve.

Difficult intubation in the ER or ICU: This information may be included in the emergency medicine admission note or in-hospital procedure notes.

Difficult intubation at an outside hospital: This might be found in an admission note, but it is frequently lost entirely. Some patients may be aware of a history of difficult intubation, but most are too ill to tell us.

Intubation is often required urgently. It is usually impossible to hunt through all of these different locations in the chart beforehand.

Existing communication strategies are uncommonly used

Several approaches have been proposed for communicating about difficult airways, including the following: (Barron 2003)

The following strategy is intended as an addition to the strategies listed above. Using several redundant strategies reduces the risk that all strategies will fail simultaneously.

“Rocuronium Allergy:” Making electronic records work for us

A simple solution to organize this information within the electronic medical record is as follows:

If a patient has difficult airway anatomy, this can be entered in the chart as an “allergy” to rocuronium. Under the comments section, describe the difficulty encountered and refer to other notes which provide additional details.

This “rocuronium allergy” will naturally be carried forward in the chart.

Prior to intubation, the chart may easily be checked for a “rocuronium allergy.”

The “allergy” section of the electronic medical record is an ideal place to put this information because it will follow the patient everywhere they go. Every electronic medical record system has a place to put this information, allowing for seamless transitions between different hospitals and various settings (e.g. OR, ED, ICU, etc.). Physicians and nurses frequently review the allergies, so listing a rocuronium allergy could promote ongoing awareness about airway difficulty across the entire treatment team. Finally, patients are usually aware of their allergies, so this might even facilitate communication about airway problems if the patient presented to a different hospital.

But… it’s not a true allergy?

Purists might protest that this is not a true “allergy,” making it inappropriate to file this information in the allergy section. Perhaps it might litter the allergy section of the patient’s chart? Well, we’ve all seen allergies ranging from “broccoli” to “non-dilaudid opioids” to “haloperidol.” Most entries in the allergy section aren’t true allergies. Adding one additional entry for rocuronium won’t change this.

Documentation and retrieval of information about airway anatomy is a critical task that we often fail at.

If a patient has a difficult airway, this can easily be documented in the electronic medical record as an “allergy” to rocuronium, with an accompanying description of difficulties encountered.

Using the allergy section of the chart may facilitate propagation of this information across different settings (OR, ER, ICU), rapid retrieval, and ongoing reminders to the treatment team.

This strategy may be used in combination with other strategies (e.g. informing the patient, MedicAlert bracelets) to reduce the likelihood of a breakdown in communication.

Notes

As with all cases from the Genius General Hospital, specifics of the case including dates, gender, and hospital identification have been scrambled to protect patient confidentiality. A case resembling this case occurred at some point in time, somewhere in the Northeast United States, within the past fifteen years.

Image Credits: Sign created at www.mysafetysign.com. Difficult intubation image on ETT from the Journal of the Anesthesia Patient Safety Foundation here. Difficult intubation bracelet intubation is from the same journal, here.

As a healthcare provider who often has to establish an emergency airway with little to no patient history on hand, and having a personal interest in patient safety, specifically patient care transfer errors (both in-hospital and prehospital) your article began ringing numerous bells for me. Many options exist to improve the transfer of patient care information to not only reduce errors, but facilitate patient care. The airway recommendations that you present are great examples of, “somebody just pick one and start doing it.” Thank you for identifying a common, but mostly silent issues that can be addressed in a number of simple ways. Of course the paramedic side of me looks forward to the day when the same information will also follow the patient to the various providers that he or she sees outside of the hospital. I would venture to say that most senior paramedics had experienced cases very similar to the one you described in which they recall a critical piece of patient information simply because they recognized the patient, but that was not passed on anywhere detectable in the patient record. I can only hope for a greater understanding of HIPAA among clinicians and administrators along with… Read more »

Thanks. Although the “allergy” approach might not be highly effective in the pre-hospital realm, it still could work (e.g. if a patient’s loved one was aware of the “allergy”). Also, an airway “allergy” raises general awareness of this entire issue, and may encourage other approaches (i.e. medic-alert bracelets etc).

Don’t get me started on HIPAA. It might be easier and more feasible to establish a nation-wide difficult airway registry without it.

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2 years ago

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canoehead

Why not an allergy to just “airway?” Then we’ll still be able to use roc.

Josh- great post. I have run into this twice- once was as a medical student when I noticed that an ED patient had a medical alert bracelet. He told me that an anesthesiologist told him to get one after they had “a hell of a time” intubating him. Seemed like a wise and practical solution to the problem. It’s certainly not foolproof (mostly due to patient compliance and us providers not searching meticulously for them in the heat of a resuscitation) but I agree with the layering approach to this issue. The second time was when I was working in an Army primary care clinic (yes I am EM residency trained- no comment other than “needs of the Army”…groan) when I was walking by another section when I overheard a nurse or medic say “difficult airway alert tag? Why would you need one of those? We would just give you meds and intubate you!” I stopped right in my tracks and asked to see the paperwork. Sure enough- an anesthesiologist from our hospital had written a detailed memo about how this young healthy soldier with no medical problems (and no outward predictors of a difficult airway except maybe a short… Read more »

Thanks, Steve. I have on occasion encountered this type of arrogance/denial in response to a patient having a documented difficult airway (“well, they couldn’t get it, but I’m sure that I could!”). Let me just say that when in doubt, it’s always better to assume that the airway will be harder than it actually is. If possible, an awake intubation (e.g. with either a Glidescope or fiberscope) may be the safest way to go – especially if documentation is sketchy and its unclear what you’re getting into.

Great post Josh. We have gamed our CIS to use the allergy list for a small number of alerts based on our high risk areas, including identifying patients who don’t want blood products based on religious beliefs. As always developer intent and user experience quite divergent in clinical systems. Thanks for spreading the word about a novel work around.

In some EMR’s have separate tabs for problems separate from the PMH that would be a good place for a difficult airway ID. I’ve seen this documented in some patients I’ve seen in my shop that have been put in by CRNA’s prior to OR cases. Listing it there or in the actual past medical history of a patient’s chart may be an alternative to sticky argument regarding allergies that are not true allergies.

Yes, this is a reasonable approach, but I would still favor using the allergy list for the following reasons. First, the problem list can get extremely long for some patients (30+ items), so sifting through it in an emergency airway situation takes a long time. Second, the problem list tends to get viewed less frequently than the allergy list (which is often checked by physicians and nurses), so using the allergy list is more likely to continually remind the team that the patient has a difficult airway.

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2 years ago

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BF

We use the problem list (if you are an epic customer) and a banner alert at my institution. It is very successful and avoids some of the challenges above. There is also a dedicated difficult airway team as part of a comprehensive solution. Message me off line for details.

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2 years ago

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Megan Anders

We are implementing a standard to document in the problem list but would love to learn how you’re triggering the banner alert. Would you be willing to discuss? I don’t see any contact info affiliated with your post – my email is mgraybill (gmail). Thanks!

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2 years ago

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Megan Anders

I agree with all your points regarding inadequate communication and wanting to make the EMR work better for us and our patients. It’s true that the allergy section of most EMRs is easily accessible and widely reconciled. However, I strongly disagree with suggesting the use of rocuronium as the “dummy” label for difficult airway, as rocuronium is an important anaphylaxis trigger in the perioperative care setting (http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2043034). Pre-intubation is a poor time to deal with questions about the “true meaning” of a rocuronium allergy documented by a well-meaning physician in a prior care episode. I suggest that for airway notification leaders seeking to make the most of their EMR allergy section, it may be feasible to work with IT to add “airway” or “difficult airway” to the list of possible allergies.